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Full text of "Use of ultrasonic waves in medicine"

BSE CF WBUU$(MBi UkWB IS MB0XXUM 



IfflSAIB ZJUBI 



B»Sc.A»H., Punjab University 
Lahore* Pakistan, 1?62 



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^fcl TABLE OF CONTENTS 

INTRODUCTION 1 

HISTORY 3 

METHODS OF APPLICATION I 

USE OF ULTRASONIC WAVES IN DIAGNOSIS $ 

USE OP ULTRASONIC WAVES IN THERAPY 18 

BIOLOGICAL EFFECTS OF UITRASONIC WAVES 28 

NEUROSONIC SURGERY J$ 

ULTRASONIC MICROSCOPE 39 

ULTRASONIC BLOOD FLOWMETER UO 

SUMMARY \a 

ACKNOWLEDGMENT % Ii2 

BIBLIOGRAPHY It3 



j tht:t;gtio: t 

Ultrasonic waves, the inaudible waves of sound, have been need in 
medicine for about a Quarter of a century. Their unique propertiee have 
bean applied in industry, signaling and many other fields before their use 
in medicine. In recent years, these wave* hare beoons increasingly important. 
Research is being perf orasd which seeks to adapt them in the various branches 
of medicine and surgery. These eaves ere now being utilised both for diag- 
nostic and therapeutic purposes. 

Diagnostic ultrasonography has certain advantages, in some eases, over 
other asthods of diagnosis. It can produce a cross sectional picture of 
pert of the body rfrtrtt* without the auperisspoeition of structures and, 
therefore, is valuable in certain b ran c he s of medicine. 

Extensive research for the utilisation of ultrasonic waves in obstetrics 
and gynecology has been performed by Donald and others (1), (2), (3), (U. 
Mew Instruments and new technics for the early detection of the fetus and 
of the fetal head before parturition are being developed. 
is also being accomplished in the field of opthalnology. Bam 
and Greenwood hold the view that no other method of diagnosis can yield the 
information as obtained by ultrasonographic technics In opthalmology (5)| 
such ae measurement of the distances between various structures of the eye 
and sise of the eyeball. 

In therapeutic medicine, ultrasonic waves have been utilized in the 
treatment of certain diseases of the spine, joints, skin, respiratory tract 
and certain painful conditions involving the nervoue system. As the ultra- 
sonic therapy advances, interest in the study of the biological effects of 
these waves is also increasing. Therefore, effects of ultrasonic waves on 



blood, tissues, proteins, liver, kidney, ovaries and other iflportant 
of the body ere being studied* 

Ultrasonic wave* eve aleo being employed far the surgery of the brain* 
It has beeoee possible to produce effects of the desired dim e n s ion s and 
location, deep in the brain, without causing damage to the intervening or 
the surrounding tissues* Principles and technics of the neurosurgery with 
ultrasonic eaves ere being further investigated by Fry et al. 

In veterinary medicine, ultrasonic eaves ere utilised lees frequently 
and their uoes are confined mainly to tberepeuUc purposes. For diagnostic 
pu r po se* these waves are seldom used in veterinary nedicine* 

The purpose of writing this report has been to collect information on 
the principles of utilisation of ultrasonic waves in diagnostic medicine end 
their physical and physiological influences on which is based their implication 
in therapeutic -adi c ln e * 

It is hoped that this report will prove helpful in providing a better 
understanding of the basis of ultrasonic waves in medicine* It may also be 
useful in the possible application of the principles and procedures of the 
ultrasonic diagnosis and therapy as used in human medicine to the conditions 
in which these waves have not previously been used in veterinary medicine* 



Ultrasonic or supersonic waves ere the sound waves of frequencies beyond 
the range of audibility of human beings, their frequencies are acre than 200 
kilocycles per second (roughly one hundred times higher than the upper Unit 
of huosn hearing)* They represent a purely mechanical vibration and are quite 
dietinct from ionising radiation of any sort (6). 

Jh non-viscous fluids, this save notion is propagated as a longitudinal 
wave while in the viscous fluids and solids a shear or transverse wave is also 
propagated in the body of the material. A rayleigh or surface wore is pro- 
duced at en interface (7). The property of ultrasonic waves to be converted 
into different types of saves in different media made their use possible in 
the different fields. 

OMH 

In 1880 the piaaonlsetrlc effect was discovered by the Curie brothers (8). 
It vas found that certain crystals, such es quarts or barium titsnate, develop 
electric charges at their ends when compressed along their axis of symmetry. 
Conversely, when charged electrically, they change their length. If an alter- 
nating current is applied to a slice of such a crystal, a longitudinal nave is 
generated by the movement of the crystal and ultrasonic waves are produced. 
Ultrasonic saves sen also be produced by magnetostriction (106). 

Langevin was ens af the first to apply piaacclcctrie effect for the 
generation of ultrasonic saves (9). He mas oomsUsioned by the French Oovern- 
ment during the First World War to find the means of locating enemy submarines 
which at the time vera attacking the French vessels. Ultrasonic waves were 
considered to be the best means for this purpose because they are in au d i b le and 
can easily propagate in water. These waves were traversed in all directions. 
In the presence of a submarine, the waves were reflected as en echo sad could 



be recorded. Since then altraaoale, were* have been widely used. Successful 
attempts to adapt them to industrial use mm not reported until 1933 (10). 

The first knoira report oonosrning the conduction and absorption of 
ultrasonic sates in human tissue ass published in Cierraany in 1939 (11 )• Vex? 
little work in this flald was dons in tha next five years. It ass during ths 
Second World War that radar and sonar technics vers developed. Prindplss of 
these instrunsnts supplied the basic information which led to the development 
of modern ultrasonic diagnostic technics in medicine. 

In 19h£ Firestone utilized the supersonic reflectoscops for the local- 
isatlon of floss in metals (12). In 19t»8 Ludwig and co-sorksrs first 
published data shoving that the ultrasonic echoes could be received from 
gallstones and other stru c tur e s within the human body (13). Hoary also 
succeeded in obtaining a cross-eectlcnal representation of the structures in 
the fore am, a cancer in the breast and a gall bladder filled with calculi 
(Ub). They employed the poise echo and horisontal scanning technics. Wild 
(15) and Bead (16) used similar technics and demonstrated the thickness of 
the bosel wall. Later, Wild and co-workers (1?) examined the soft tissues 
of carcinoma of br ea st and tumours of brain. After these initial developments, 
work with ultrasonic saves use accelerated in many countries. In this say a 
new tool of biological research was developed* 

H3ECK5 CF APPUC/.TION 

ultrasonic saves are applied to the body through a probe or head of the 
instrument producing ultrasonic saves* It propagates ths saves into ths 
tissues. Intensity of ultrasonic saves is msasured in watts per scjuare 
centimster. 



Ultrasonic uaves are rapidly absorbed in the air. Therefore*, to help 
walntoln on aeo w r w ta contact between probe and the skin, it is xamessary 
for the hair to be removed from the site of ultrasonic application* In 
addition to it, a contact ooditsn is also applied on the skin in order to 
avoid any air space botMosu probe and the skin* particularly en the uneven 
areas of the body* Contact Media commonly used are mineral oil, ointments 
sad a gelatinous substance one—rot ally pr e pared for this purpose* Warzdng 
of the ccntact medium Is considered by sent workers to render the ultrasonic 
waves acre affective (16). 

flewtliens the ultrasonic waves are applied under water* This iiimsrtMi 
is easier to carry out than is the use of contact mediua and eliminates the 
possibility of the presence of any fila of air under the probe* In the 
apt id cm of sows workers this method is preferable to the contact medium 
Method 0s)» It is considered most useful for arses of the body where a 
close contact between the skin and probe cannot be maintained, particularly 
when the probe has to be moved around* 

Treatment tisrough water can also be carried out with the help of a 
special funnel* chair (20) or a rubber container filled with water (21)* 

vb op vumsmc waves in diagnosis 

artrenely short pulses of ultrasonic waves are being utilised for 
diagnostic purposes in human medicine* Kaeh pulse lasts for only a few 
mlllionths of a second* the average power levels used ere approximately 
cnewfehousandth to one one-cdllionth as great as those used for therapeutic 
purposes* Juch low intensities of ultrasonic waves are not reported to 
esmrt any biological I rrflu onoa on the body. It is, therefore* generally 
stated that the diagnostic value of ultrasonography depends upon the body'a 





Figure / Illustrating that echoes can be detected from tissue interfaces only if the sound 
beam crosses the interface at right angles as in (a). At other angles of incidence (b), 
the echo does not return to the probe. 







,/l /.v V, 

// »,' y, I v* 







FigureZ(Left). Three overlapping sector scans. At each position of the probe it is rocked 
through an angle of about ± 30 from the perpendicular to the skin at that point. 
The broken lines each represent the path of a single pulse of sound energy. In 
practice a pulse is transmitted every \° of each individual sector scan and there 
are about 50 or 60 overlapping sector scans equi-spaced round the skin. 

(Right). A cross-sectional display showing the left-hand figure superimposed on 
the echo pattern which would be recorded if sector scans were carried out only from 
the three positions of the probe on the skin. 



courtesy: Charles C. Thomas, Publisher 
Springfield, Illinois, U.S. A 



effect on ultrasound, whereas the therapeutic value depends upon the ultra- 
sound's effect on the body (22) • 

tatrasonogrephy ie baaed on the prlncdpleo of echo ranging, which ia 
also utilised in radars, echo sounders and submarine detection equipment 
wad at sea. In radar the energy used is in the fern of eloi tnamgnatic 
wares* These S i m travel much faster than sound waves and can be used for 
^Ifttanpf of hundreds of miles* In other technics sound waves are used which 
travel noch slower than eleetrcmagnetic waves and operate on short dist a n ces 
of only a few centimeters. 

The sound waves travel in straight lines acre or less at a constant 
speed through the tissues. Whenever these waves impinge on a tissue inter- 
face, sob* of the sound is reflected as an echo* When the echo returns to 
the probe it can be detected. For the detection of echoes, it is iie o cai aj'j 
for the reflected waves to return to the probe* In practice, however, all 
the echoes do not return to the probe* When the sound waves iapinge en a 
tissue interface, the reflected waves return along the path of the incident 
waves if the interface is at right angle to the direction of notion of the 
sound* The waves that do not obey this rule do not return to the probe and 
are lost (Fig. 1). To avoid the loss of reflected waves, automatic seanning 
devices have been developed which maintain the probe at a constant pressure 
and desired angle cat the skin of the body* 

By making certain electronic modifications, the recorded echoes can be 
presented as bright dots of light on an oscilloscope (Fig* 2). An oscillo- 
scope utilises a cathode ray tube which is the type of tube used in television 
sets (23)* A cathode ray tube produces electrons from the electric currant. 
The electrons are accelerated along the axis of the tube and at the same time 
they are f ocussed onto a flourescent screen* At the point where they strike 



JXPWHMf ZOH <F PIAffi z 
A, liltawoooeras of & ncarnal bunas log* 
B # Ultr«»Qnogri» of * annul 



( I MrfMM 



y, amth KUj» - Precision 



PLATE I 





10 



the screen a bright spot of light appears (2l>). The distance between the 
dote represents the tiiae vhlch elapses between the poise being sent oat end 
the echo returning to the probe* Oils gives a measure of the dlstsneee of 
the interfaces from the probe. The intensity of the dot represents the 
strength of the returning echo and gives the density of the interface (2$). 

After all the echoes have returned to the probe a new pulse is generated 
and passed adjacent to the path of the previous pulse* In this way a new 
line of spots adjacent to the pr eeee dinc line is produced on the oscilloscope* 
Hwjseanrts of pulses are famed every second and passed in a slightly different 
direction through the object being studied. 

A camera is placed in front of the oscilloscope screen and shutter of the 
earners is left open* Wiile the probe is being scanned in a regular pattern 
fron one side of the object to the other and while siwultancously the lines 
of dots are being produced on the screen, their images are f ocussed on the 
film. «hen the film is developed, the transient flashes of light are seen 
to have joined up to form a areas ssctional view of the part of the body 
exswdned* This picture is an ultrasonogram (Plate I)* 

Two types of technics ere generally used for the application of ultra- 
sonic waves for diagnostic purposes* These are Aec o po, or amplitude depth 
technic and the B-ecope, or conpound seen technic uith or without focused 
sound been* The A-ecope presents the echoes in relation to time and distance 
on a single line and single direction only (26). The B-ecope is a compound 
essnning technic. It propagates the waves in many directions* It is possible 
with this technic to obtain more reliable pictures of the structure being 
etudied (Fig. 3)* 

Diagnostic ultrasonography, in certain cases, is more useful than other 
diagnostic aide* It gives a cross-eection view of the pert examined including 



21 




Figure 3 (Top). Diagrammatic cross-section of the abdomen of a hypothetical 
patient showing (broken line) the path of the sound energy originating from the 
probe at (i) and crossing interfaces (2), (3), and (4). 

(Lower left). A-scope display showing the time-base which moves from left to 
right and is deflected vertically by the 'transmission break-through' (1) and echo 
signals from the interfaces (2), (3), and (4). 

(Lower right). A 'compound' cross-sectional display showing the time-base originat- 
ing from the point (1) corresponding to the probe position on the patient's skin, 
and moving in the direction of the sound. Signals from (2), (3) and (4) produce 
brightness modulation of the trace. 



courtesy: Charles C. Thomas, Publisher 
Springfield, Illinois, U.S. A 



12 



the soft tissue structures which may not become easily visible by other 
methods. An ultraiKMogra*, aoreover, Is obtained without the iwperiapoeition 
of structures which is characteristic of radiographs. It nay also help in 
the detection and detezminetion of the position of abnormal tisanes or foreign 
bodies which radiographic examination may not reveal. 

In hunsn medicine, the diagnoatic ultrasonography is used aost ccmmnay 
in neurology, cardiology, obstetrics end gynecology, internal medicine and 
ophthalaology. These waves are also being used in seas other branches of 
Medicine but cooperatively to a lesser extent* 

leksell *as the first to describe *iat has cone to be known as echo* 
encephlography (27). Oordon (28), 7Ue^» ©£ Si- tBk ?*&* (30) and amy 
others have also aade important contributions to this subject. The progress 
with ultrasonic diagnosis has been slower in the central nervous systen thai 
elsewhere* This is because the intact skull creates a significant barrier to 
the tranaaiseioa of sound waves* In the temporal bone, for example, the half 
intensity power distance at a Billion cycles per second is 3/2 an* (31)* This 
resistance to the conductivity of the ultrasonic waves, results in the pro- 
duction of heat which aay have a haraful effect on the brain tissues* 

Ultrasonographic technics have been found to be of value in making an 
accurate measurement of the midline displacement of the brain (32)* This is 
determined by aeasuring the distance to the middle from both sides of the 
skull* This method is considered extremely valuable in the differencial 
djagneeis of acute cerebrovascular aoeddente, and could readily distinguish 
hiitaenn osier arterial occlusions and eoace occunvine hematomas* cranial 
abscesses and complications due to intracranial injuries (&)• 

Location of tla cerebral ventricles by ultrasonic waves was first 
performed by Ballantine et a£* in 1900 (33)* This was performed without the 



23 



injection of air Into tlie ventricles. Tumours of the brain have been detected 
by Tanaka ej a£. (3b), (3$), (36), (37), Ctarden (28), Taylor et a£. (30) and 
many other workers. A heart cam of the brain can also be detected and it is 
possible to dlfferenciate it from other speee occupying lesions, as reported 
by Taylor et al.. Location of the hematoma, whether eubdural or extradural, 
can also be determined by this technlc (29)* 

Ultrasonic waves have also been used for the study of the hypophysis 
(38), small localised lesions in white and grey matter of brain (39), intra- 
cranial lesions following injury (32) and examination of tl» pineal body 
0*0). fry and co-workers have reported a method of differentiation between 
pathogenic math ■ills— underlying a parkinsonian tremor and rigidity en 
indicated by ultrasonic Irradiation of the human brain (&)• 

The ultrasonic awes are used in cardiology. In this branch of medicine, 
ultrasonographic technics have bean used to produce ultrasonic oardiograae. 
With this technlc, rrv mo art of the left ventricle wall in the normal and in 
the diseased heart as well as arsvaamtB of the left atrial wall in antral 
stenosis have been reported (U2). It is also possible to make a continuous 
recording of the lew— 111 of the heart wall (13). It has become possible 
to determine volume changes in the heart by the method devised by SaLdel 
and Arvideson (1£). Comparative studies on heart patients during the 
decompensation and recompensatlcn stages of the heart have been performed 
by Schmitt et al. (h6)» 

Atriovontricular -valve motility and the mitral and aortic valve aaasimi 
ncnte have been r e c o rde d in living human patients (li7). Structures of the 
heart can be studied by the intracardiac method developed by Ciosaynski (18) # 
It is also possible to diagnose abnormal structures pr e sent in the heart by 



mwwnm of plasb n 

A* Photograph of transverse ©eta of aaaaal 

iHMftNMMl 

B # Photograph of transverse scan of huHtt 
abdomen distended by a large ovarian qwt. 



Courteay, Madleal and Biological IlluatratlonB 

Imam 



PLATE II 




35 




2d 



close scrutiny of the ultrasonic cerdiograa. Detection of intra ■iricular 
tuaours and throabl has been reported by Effort and Dcnsnig (U9). 

In obstetrics end gynecology* use of ultrasonic waves is becoming quite 
ajgrrifloant in certain instances* It has been found that the fetus can be 
detected by ultrasonic echoes* This detection Is possible raany weeks before 
the fetus sen be seen by radiographic osthode (2)* The tissue interfaoe 
can be reooztisd by ultrasonic wavee nuch bef cape the fetal skeleton can be 
re corde d on a radiograph. Hbrsel or ahnoantal pr es en tation of the fetus can 
also be detected by the detersdnatlon of the position of fetal head. Certain 
conditions of the ovaries* such as ovarian donsald cyst and ovarian enrd- 
no wa t o ei s have been identified by the use of ultrasonic neves (£0), (Plate II). 
Diagnosis of hydatifora nolee end fibroid tussore is also possibla (3)» 

Meaeurenent of the fetal heed hee been carried out In a nueber of eases* 
Such rjcesiaeraente ere very useful in anticipating pceoible difficulties in 
perturition. CepheJUxtstery with ultrasonic ware* hee been found quite 
accurate wien capered with caliper msieuwiiwita of the heed after delivery 
of tic fetus* An error of even 2 8% In the opinion of the workers, can be 
regarded as a poor result (2). 

In Internal e edi c l. n o, ultrasonic waves were first utilised wien Ludwig 
ot al. m icee ed e ] In detecting stones in the gallbladder aid foreign bodies 
in tissues (51)* Sise* shape and structure of tuaours was studied by tfiid 
and Beid (52) and others (i>'3), (51). Ibis was done in intact living 
bodies* Other soft tissue structures of the body could also be 
(#), (57). 

TJltreaonog r e ph le teehnles have been used to visualise the anafcedcal 
of edeoatoue fluid in various parte of the body (50)* Detection of 



17 



is based on the separation of two tissue Interfaces in an ultrasonogram, 
which in a normal cose, should be located close to each other* It is reported 
that an ultrasonogram will reveal a carcinoma of the breast dnleh was not 
palpable prior to the surgery (59). 

Foreign bodies, tumors, henatcwas, a b sc e sse s and cysts can also be 
detected by the use of uHarasonie waves (51), (53), (57). Maamirananai of 
the dimensions of internal organs in the living antral la described by 
(60). 

Work has bean done with the use of ultrasonic waves In ophthalmology. 

and Oreenwcod hold the view that no other method can yield the infer- 
nation which is obtained by ultrasonographic technics in ophthalmology (5). 
T a.s t a no es b etw ee n various structures of the eye, such as between the lent 
and retina, and size of the globe of the eye can be Measured by ultrasonic 
waves (61), (62), (61*). Detection of intraocular foreign bodies (63), (66) 9 
(67) tuaours in the orbit (65) and hemurrhnj» in the vitreous charter (66) 
have also been reported in the literature. 

Ultrasonic waves are very useful in the diagnosis of certain other 
oonditione of the eye. Acute dacryocystitis, for example, can be determined 
by the use of ultrasonic waves (69), (70). Chcrodial attachment (71), 
rupture of the sclera (72), (73) and detachment of the retina (7U) have 
also been diagnosed. 

In dentistry, ultrasonic waves have been utilised for the examination 
of internal structures of teeth (75)* It has been found that the absorption 
of ultrasonic waves increases as the vitality of teeth decreases. This 
principle forms the basis for a sensitive method of measuring the viability 
of a tooth. It makes possible the detection of caries in very early stages. 



xs 



since the carious process causes alterations in the structure of the teeth 
and an acoustic interface is established* 

Ultrasonic waves ham been anployed in the diagnosis of cancer* The 
basis of such a diagrwisia is the fact that the intensity of the sound which 
returns from the cancerous tissues is pester than the intensity of sound 
that returns from equivalent surrounding normal tissues (76), (78). Ultra- 
sonic diagnosis any be possible in the early stages of cancer (77)* 

In — *rV» husbandry* the principal use of ultrasonic saves is in the 
detemination of the thickness of muscles in bovine and swine (79), (Go). 
These liamirenejita are useful in the selection of neat animals that produce 
a h±&x percentage of their weight in the acre desirable cuts. Other 
methods presently used for determining f era animal physical composition are 
human Judgement* knife probe, conductivity prove and carcass analysis* 
Animals which are probed with a conductivity probe or a knife are subject 
to infection in the Incision* None of the old asthuda are considered to 
be completely satisfactory in r e sp e ct to accuracy, convenience and cost. 
The ultrasonic method, therefore, seems to be the most desirable method* 
Ultrasonic method for the determination of the thickness of muscles has 
been reported to be reasonably accurate (Si)* 

The entire field of ultrasonic diagnosis is based upon the preparation 
of good ultrasonograms and their correct interpretation. Interpretation of 
the ultrasonograms is the most critical aspect* It requires the knowledge 
of normal structures and ultrasonograms of the part of the body evaained. 

OP UmiSCKTC NAVES IN THK8APY 



It is reported that sound waves were used for therapeutic purposes in 
the middle ages* A big musical organ was provided with a glass sound board* 



2$ 



Patients placed on ttda sound board vers subjected to vibrations. This 
tr e ata i ant vae performed mainly on rasatal patients (82). 

In therapy, relatively high levels of ultrasonic energy are used ahioh 
produce aewhanical and physiological effect*. The therapeutic value of ultra- 
sonic wires, therefore, depends upon the effects of these wares on the body. 

The intensity of ultrasonic energy used in therapy ranges froa 1 to 3 
watts per en 2 . At one megacycles per second the wolsculee of the 



execute snail oscillations about their nean positions with an amplitude of 
shout 2x10 em, or 0.02 adcrons. The greatest velocity of the particles is 
about 10 ca par a e eon d sad the maximum acceleration during their to and fro 
mo vem ent is 7x10' em par second per aeeond. Therefore, although the linear 



and velocity of the Individual particle is low, the acceleration ie 
very rapid. This nay give rise to local disruptive forces, not greet enough 
to break up molecules end produce chemical changes, but greet enough to 
produce mechanical changes. These nenhantfal changes, nay alter the bio* 
logical membranes which then result in an increase in the permeability of 
the l u ee ju'a w ai to fluids. Mechanical changee also cause a rise in the 
temperature of the tiasses (83). 

The thermal effect of ultrasonic waves is generally considered to be 
the stain therapeutic effect of ultrasonic treatment. However, some 
inveetigetcrs are of the opinion that besides the thermal Influence, an 
unknowi action exists which aide in the recovery of the patient to an ex- 
tent wore than could be accounted for the theraal effect alone. 

Another effect of ultrasonic therapy la fluid absorption. When the 
dosee are adequate, fluid is increased in the interstitial tiaaues. It is 
supposed that the gels are changed to sols due to absorption of fluids. 



«> 



Purine thsrepy, ultrascnic wwee en be applied to the patient by 
various methods. These methods ere aimed at scldeving the greatest benefit 
by influencing, In the most suitable way, the pert of the body to be treated. 

In local treatment, ultrasonic neves are applied dJreeMy on the affected 
area. Treatment of the cutaneous lesions with induretlon, such as haloid, is 
en exanplo of local treatnont. 

Ultrasonic wares nay be applied to the nerve plexus along perlphcrel 
nerve trades. This is thought to inflnenee the organs at the nerve endings* 

Ultrasonic application to the autonomic nervous system produces a 
sedative action on the nerves* The sound saves in this method of tr e atm e nt 
have a specific effect on the nervous system Iimbu sb the nerve plexuses ere 
selectively heated with respect to su r r ounding tissues (81). 

In contained therapy the use of ultrasonic waves is accompanied by some 
other form of treatment. The ultrascnic therapy may be combined with physical 
message* x-rays, warm water bath, electric stimulation or a cooling shower 
at the site of irradiation. The combined method is employed to enhance the 
heeling effect of the treatment. 

Doppelechell or ; opplcr effect has also been applied in the ultrascnic 
treatment. The treatment la given by two persona each with an apparatus. 
Cms application is on the central area of the back with lower intensity and 
the other, on the peripheral area with relatively higher intensity of the 
waves. This method has been used for eases of cnkylnclng spondylitis which 
do not respond to other forms of treatment (85). 

Ihdleations Tor ultrasonic treatment ere nuemrous. It has been utilised 
for diseesea for which no efficient trwetssmt was previously known. It has 
also been tried as an aid to other methods of trestaents. As a result, the 



list of diseases that can be treated with ultrasonic saves has consideydbly 
increased* The f ollowing diseases have auooessfnlly been treated with ultra- 

8CQXC HUVMIi 

In human medicine, the dlssssss of the vertebral column that are generally 
treated with ultrasonic waves are spondylitis, de ge ne r a tion of Intervertebral 
disc, kyphosis, scoliasis and kyphoc< oliasis. 

Aeaording to Van Went, who treated about forty cases of intervertebral 
disc a/udru ae la huaan beinss, protrusion of the nucleus pulpoeus in eases 
of disc syndrom nay be caused by rupture of the auanlus fibrosus due to 
trauma of the vertebral column. Rupture of the annuluo fibrosus occur when 
It beeonss de g en e rate d and tension on the nucleus pulposus is incre as ed 



Nutrition of the disc cones partly from the spongiosa of the vertebral 
bodies by osmosis through the cartilage. A normal vertebral body is, there- 
fore, necessary for normal mstabelisa of the disc* Diseases of the spine are 
generally associated with calcium deficiency of the skeleton, which may be 
detected in a radiograph, Ibis should be considered es en abnormality of the 
astitioTlnm of the bony substance lewtln e to e d er ang ed atrleholism end 
degeneraticn of the intertertebral disc. Calcium deficiency of ver t ebr ae may 
be partly due to delayed protein mstabolism because the old protein is act 
eapeble of taking up calcium, The favourable action of ultrasonic therapy 
in snail eases is probably due to the stimulation of metabolism including 
protein metabolism, and thus increases the calcium absorption (86), Simul- 
teneous use of calcium, vitamin D and exercise increase the efficiency of 



Doses of 1,5-2 watts/cm 2 have been used for the treatment of inter- 
vertebral disc a j ud ru u s la huaan patients. This treatment was given for a 



duration of £ ataxies and was repeated twice a week, This was accomplished 
with a sewing head vertebrally and p a raver t ebral^. Tha waves were applied 
to two ve rtebr a e above and two vertebrae below the disc that was involved. 
An increase in pain and aggravation of the condition temporarily followed in 
sock of the eases following each session of treatment (87). Pain was not 
observed following the doses of 0.5 wotta/aa 2 (Co). Damage to the inter- 
vertebral disc amy also cause dstaehnent of the periosteum along the margins 
of the vertebral body. This detachment nay lead to irritation and 
bene formation on the vertebral bodies (82). 

Satisfactory results here been reported with the use of ultrasonic 
in treating diseases of the spine (09), (90), (91). Whether the 
applied with a stationary or a moving heed is inportant in treating 
diseases. Application with a moving head gives better results than with a 
stationary head. The stage of the disease at which the t r e ct i wit was began 
is also very inportant. Most of the practitioners feel that no favorable 
effect nay be expected if ankylosis has already developed (90), (89). With 
the use of a stationary head, severe pains have been reported to occur on 
the non-treated side. This phenomenon was observed by Zinn and Sonnensehain 
and was termed as ' Schsufcelnhcmomen * or swing ph ene w js non (92). This 
phenomenon has not, however, been reporte d by other workers and does not 
occur when the head is moving* 

In addition to Van Vfent'a explanation of oaleium absorption following 
ultrasonic treatment, other views concerning the beneficial effect of ultra- 
sonic waves on vertebral d is eases have been suggested. Some workers attribute 
the heeling process in these diseases to the absorption of fluids by the 
tissues and to the thermal infuence of the waves on the tissues (93), (9h). 
If the fluid content or the annuluo fibroses becomes lower than normal due to 



23 



deranged i»atabolien, it will not be able to stand Increased tension in the 
disc and the annulns flbroeue nay be ruptured. Absorption of fluids from 
the surrounding tissue may bring the fluid content of the annulus fibrosua 
to nonael and improve its function. The possibility of cavitation or sons 
other specific action of ultrasonic waves has boon proposed (9*0 • The 
results of experiments perf onaed by Hasoue et al* indicate that under 
experimental ccsaditions, ultrasonic waves act on the uhruuuj of the nervous 
system by a mohardam different from that of thermal effect or cavitation 
(96). Whatever the underlying mechanism of healing nay be, ultras nic waves 
have a beneficial effect on the vertebrae as wall as on the surrounding 
tissues* The vertebrae are strengthened by calcium absorption and the 
supporting tissues softened, so that the function of the spine inproves. 

Diseases of the joints in vhlch ultrasonic waves are useful are arthrosis, 
periarthritis bnrasroscspularis ( TXtplay's disease ), epicondylitis, teno- 
synovitis and arthritis. According to Pohlnan the clinical effect of ultra- 
sonic therapy on diseases of joints is narked (97), (96). He risjnils i* a* 
the treatment of choice in arthrosis of the hip joint. In arthrosis deform- 
ans, ultrasonic therapy is considered to be superior to x-ray therapy (99). 
In Ouplay's disease, d i s appea r ance of pain, Increase in nobility and re* 
sorption of oaleiuw have been reported after ultrasonic treatment (100). 

Rheumatic joints haws been treated with a combination of ultraaonia 
Haves and cortisone* The cortisone is dissolved In glycerol and used as a 
contact rwdiw. This treatment is based on the phenomenon of phenophoresis. 

Cases of bronchial asthma have been treated with ultrasonic waves* In 
the mild oases of this disease, 70 to 80 per cent recoveries haws bean re- 
ported by Anstett (101). In mere severe esses the recoveries were 60 to 70 



a 



par cent. The waves, in this treatment, inn applied over the stellate 
p jii. ij 

Ultrasonic treatment of asthma is soaetlaee combined with very snail 
doeee of x-irradlation. With this type of treatment, forty-three out of 
forty-five eases neve been reported to remain symptom free for five years 
(102). Intensities of h-6* watts/oar> **om » stationery head were allied 
for 10-12 minutes daily during this tre a t ment . 

It is believed that air in the lunge impedes the penetration of ultra- 
sonic naves (hiring toe treatment of diseases of the chest. The rigid thorax 
is observed to become placid after ultrasonic treatment. The vital capacity 
of the lungs is increased following ultrasonic treatment end the respiratory 
oaa msl on Is enlarged. The patient experiences less respiratory difficulty 
due to increased expectoration of mucus after the treatment. The physio* 
logical bases of ultrasonic treatment cf bronchial asthma may be explained 
by the fact that bronchi of asthmatics contain a tough mucus which is 
e xp ectorated with difficulty. Ultrasonic waves era known to increase the 
fluid absorption. The fluid is taken from the surrounding tissues* When 
these waves are applied to the mucus, it also absorbs fluid end becomes 
eoft and flabby. Therefore, expectoration becomes easier (103) • 

Pulmonary tuberculosis has been reported to show an iwjaw ej usut follow 
lag ultrasonic treatment (10fc). The value of this treatment, however, depends 
upon the stage or type of lesion present in the lungs. If an active infection 
is net present, ultrasonic therapy may help in a favorable way by breaking of 
the nodule. If, on the other hand, the lesion is infective, ultrasonic 
irradiation may cause dispersion of the infection in the surrounding areas 
of the lunos (10£). In the opinion of Van Went, ultrasonic treatment in 



2$ 



tdbtorculoua pulmonary lesions should be disf avoided both in active and Inactive 
conditions of disease (02). 

There is a great divergence of opinion in regards to the usefulness of 
ultrasonic eaves in cardiac diseases. Sons authors regard the use of ultra- 
sound in these dlssaess ae an absolute contraindication. Others hold the 
view that there is a favorable influence from ultrasonic eaves on certain 
cardiac diseases. A eaee of cardiac infarction has been reported by Dealer 
which ess treated with high doses of ultrasonic waves over the stellate 
ganglion and preaortic plexus. The pain decreased and the feeling of 
opressdon disappeared (107) • Certain vascular conditions such as angio- 
spasm, arteritis obliterans (IOC), (109) and Hayneud»s disease (110) have 
been reported to show jjsprevensnt following ultrasonic treatment. Great 
caution, however, is necessary daring this type of treetnsnt. Jeak vessels 
may rupture dee to vibrations of vessel vails and thrombi may beeone loose 
and form enboli following ultrasonic treatment. 

Ultrasonic treatment has been applied in soms oases of gastric anil 
ulcers (111)* Such tweet i as it be* little effect on fresh ulcers. 
r, in indolent ulcers satisfactory results have been reported following 
ultrasonic treatment. Perforation at the site of an ulnar is possible as a 
result of vibrations produced by the waves. 

Intestinal peristalsis has been shown to Increase after ultrasonic 
treatment in children and babies (112). Movement of the head of the 
a pp a r a t u s Is n s usasaiyy to produce this effect. Ultrasonic waves have else 
been need in esses of pylorospssm. Phloroepesm has been reported to dis- 
appear after a few sessions of treetment (133). 

Meniere's disease, a p rogre ss ive deafness due, most probably, to en 
exessive amount of endolymph in the semicircular canals of the ear, has been 



^ 



treated with ultrasonic waves* A special type of instrument hat been 
deviced for the li aiilieMil of this disease. The teebnU has been developed 
by Janes (Hit), The treatment is perforaed under local anesthesia* Ttm 

are applied directly to the fluids of the labyrinth with a special 

in the intensities of 10 to 22 watte/ear* (31)* 
Tlntdtis and catarrh have also responded favorably to ultrasonic 

therapy (U5). 

Various cutaneous conditions have been treated with ultrasonic waves. 
Dttpuytren»s contracture, caused by the contraction of the palaer fascia 
leading to peraanent flexion of one or raore fingers, has been reported to 
respond to ultrasonic therapy, Satisf setory results were obtained when 
the finger was treated before complete contracfelon had oeeured* After 
contraction, ultrasonic treatnsnt nay be ooabinsd with **ray therapy to 
obtain better results (11)6)* A rubber bag filled with water has been need 
during the application of ultrasonic waved to the hand* the waves ware then 
applied with a noving head. In the opinion of Tschanncn and Sonnenechein. 
a decrease in the tonus of the pclxsris longs* ansele accounte for the 
iieproreasnt in the eases of Dupuytren's contracture (117;. 

Several unsuccessful attempts have bean aade to treat keloids with 
ultrasonic waves* Bowever* it hss been reported tliat a case of keloid in 
the scar of a gall bladder operation was cured with ultraeonle waves. Ad- 
hesions of the abdoninal wall were also supposed to exist in this esse and 
wars believed to disappear following the treatment (110)* 

Cases of painful acputation sttssp have been reported to respond well to 
ultrasonic therapy (108), (109). Pain in the stuap disappeared aa a result 
of the sedative action of ultrasonic waves* 



27 



A special techntc Tor the treatment of warts has been described by 
Buchtala (US)* A little ball of wax is placed on top of the wart, The 
waves ore applied with the stationary head of the ultrasonic apparatus Wax 
welts and form* a fountain through which the warts are irradiated with ultra- 
sonic waves. Afterwords, an areola of vaecicles develop. The wart falls off 
in approximately two weeks without leaving a sear. 

In localised scleroderma, constant success has been reported with ultra* 
aonic treattaBnt (120). 

Ultrasonic therapy has been useful in treating leg ulcers. Fifty to 
sixty per cent recoveries were reported by Xrebs (121). Sa applied the waves 
directly on the ulcers as well as to the r miniitlnc areas. He obser v ed 
e p itheli al proliferation and clearing of the ulcers after a few sessions of 
treatnant. Sons recurrences were observed, tfoeber treated twenty-four cases 
and found improvement from the first session without any recurrences after 
healing (122). 

Purulent inflsmmatory processes such as boils, carbuncles, hydro- 
adenitis and mastitis have been treated with ultrasonic waves. Satisfactory 
results in these diseases have been obtained after treatment (123), (12U). 
The moving head should not be used in such cases because the inflammation may 
become dispersed by this method of treatment. 

In addition to the diseases already mentioned, ultrasonic waves have 
been used in treating certain other conditions. A brief description of some 
of them is given below. 

Urositis and neuralgia have been reported to respond favorably to ultra- 
eonic treatment (125). This can be explained by the fast that ultrasonic 
wave* have a sedative effect on pain. All painful conditions ( algias ), 
according to Van Went, can be treated with ultrasonic waves (82). 



Ultrasonic Irradiation in eases of toxic goiter have given no favorable 
results (126)* Thyrotoxicosis* however* has been treated satisfactorily 
(127). 

Progressive anseolar atrophy is considered quite suitable for ultra* 
sonic tr eatm e n t. A ease of twelve years standing of this disease was cured 
in thirteen sessions of ultrasonic treatment (128), apathetic nerves in 
the area of progressive suseular atrophy have also been irradiated with 
ultrasonic waves* With this fern of treatment, itusken has reported inprove- 
sent in nine eases (129). The BBseulature beesne stronger in each ease* 

A ease has been reported, where, after the removal of the patella, the 
skin over the underlying tissues was only slightly mobile and the joint 
isi ten wnt was Halted. Severe pain was felt upon novoaent of the knee joint. 
After ten sessions of ultrasonic t h erap y the pain disappeared, the skin 
moved freely and the joint raovesiente beesne nornsl (82). 

Experinents are constantly being perfom e d to explore the diseases in 
which ultrasonic therapy night prove useful. Although these waves are 
utilised satch less frequently in veterinary wadieine at the present tine, 

fi ppi ^c • 

BIOLOGICAL STEMS (F UEEASOHIC WAVES 



The use of ultrasonic waves is rapidly increasing in aedicine. This 
necessitates the study of the effects of these waves on biological tissues, 
rnowledfts of the bi o l o gical effects of ultrasonic waves aids in the evaluation 
of ultrasonic therapy and gives lnforastion regarding the possible effects of 
these waves during diagnostic uses. It also helps in the deterrdnation of the 






intensities to be applied and the erects of the body or the organs tc be 
avoided visile applying ultrasonic waves. 

A study of the history of sound wares reveals that ee early as 1793* 
the results of en explosion in Landau were reported* Ifiaety-two newborn 
infants died from the sound wanes* Several other infants were believed to 
beeone cretins. In 1921 when ultrasonic waves were adapted for use in 
nsviegation, it wes observed that snail fish coming into the field of the 
ultrasonic waves were killed by the effects of the waves (82). mm a 
soell animal wes placed in oil in which an oscillator producing ultrasonie 
was immersed* the anlaal died. It was found that blood corpuscles 

destroy ed by ultrasonic waves (6). 

lbs thresholds of ultrasonie energy are very important in relation to 
its biological effects. A particular type of tissues way not be affected 
at low intensities* tut if the intensity is increased* the sans tissues may 
show some biological effect* 

There are physical factors which ac com pany the ultrasonie waves* tost* 
factors are responsible for the aanif ©station of the biological <"i«1ntmti 
brought about by the ultrasonie waves on the tissues* the ultrasonie energy 
is absorbed in the tissues* This absorption causes the conversion of sound 
energy into heat energy. An increase in the temperature of the tissues is 
one of the principal factors in the aanif estation of biological effects of 
ultrasonic waves* 

Periodic pressure changes and radiation pressure front ultrasonie waves 
are also important factors in producing biological effects. There is a 
pressure of about two ataospheree between two points half a wavelength 
( 0*75 an ) apart in the tissues. If the intensity of ultrasonie energy 
is increased to about 10 wstta/cs 2 , the pressure in the tissues increases 



30 



greatly and microscopic cavities ere formed in the tissues (130), The 
cavitation may causs severe dams* to the tissues. The cells ere broken up 
enc chemical ghanges occur. In clinical practice, however, the doses used 
ere insufficient to produce cavitat: . 

1 The phenomenon of streaming has recently been described by Hughes and 
tyborg. This explains the possible mechanism of the disruption in the 
bacterial or cellular membranes end sons other biological effects following 
ultrasonic application of the intensities insufficient to produce cavitation. 
When ultrasonic waves are applied to the tissue or a suspension of the miero- 
erganlsm, the alternation of pressure bet s e en two consecutive eaves of sound 
may wanes the formation of nicroscopic bubbles containing gas or vapours. 
It has been sheen that a bubble of a few microns in radius expands thousands 
tiaes of its original sise end then bursts into a large number of smaller 
bubbles in the form of a stream* These changes result in the production of 
a rise in the internal temperature and pressure sufficient enough to break 
the cell* Chemical changes such as the formation of Sieee radicles, alteration 
of pH and oxidation also occur. Large polymere, such as deoxyribonucleic 
acid, may be broken down by the liquid shear or disruptive f cross or by £r— 
radicle attack. Sheering in the absence of free radicles is thought to 
reduce the size of large molecules (151), 

When ultrasonic eaves wn applied to a piece of fresh tissue, 
permeability of the cell meabranee is increased and the interstitial sub- 
stance absorbs fluids which are brought in contact with the tissue (132), 
Used and Loomis first studied the mechanical, thermal, and biological effects 
of ultrasonic waves in the United States in 1927 (I3lt), (135). 

Effects of ultrasonic wares have been studied on bacteria. The bed 111 
were irradiated with 7 watts/cm 2 . This produced injury to such a degree that 



31 



they vare unable to maltiply further. These bacilli ware no longer pathegenie 
to guinea plga, monkeys and ana (236)* aterlisatioa by means of ultrasonic 
waves vara also triad. This method of starlisation killed 80 to 90 per cant 
of the bacteria* Complete cterliaatlon, however, was not possible with ultra- 
aoais waves (137), (138). Whan a bacterial auapenaion was Irradiated with 
ultrasonic waves, the suspension retaiiicd ita antigenicity (130). 

Ultrasonic waves cause hemolyses of red blood cells (lisO). This effect 
of the vavej is ascribed mainly to the aechanical influence of the ultrasonio 
wrei, Sena workers have investigated the effect of various methods of the 
application of ultrasonic waves on red blood cells. Effects of pulsed and 
flflfifrlnwif application ware studied. In the opinion of these workers, the 
period between the impulses is not significant, although it has sons in* 
fluenoe on the development of heat* The Intensity of the waves* rather than 
the duration of the application of the waves, is store important in this 
respect (lbl). tenolysis has not been observed with the therapeutic doses 
!& vfrre * Ultrasonic waves apparently attack the iiaaa imr s na s n i of the erythro- 
cytes. The sells which escape hemolysis are observed to have tiny holes la 
their aenbranes (U»2). 

flseaiMlaiM' aneada after ultrasonic therapy has act been observed, How- 
ever, an increase in the eosinophils of the peripheral bleed may be seen* 
Keeppen Irradiated the bone marrow with a dose of 35 watts per em* for 30 
minutes. He observed en increase in the blood content of bone Barrow, The 
bone marrow also showed an increase in eosinophils (Ik3) • 
i/- In a study by Spetoh ot al. certain changes in the blood ware noticed 
immediately after the irradiation with ultrasonic wares* The heneglcbln 
percentage was inereaaed while number of leukocytes and erythrocytes 
remained unchanged* A fairly large namber of Immature cells trere found 



32 



directly after the irradiation. The estlaated aedUsentetion r*to alee 
increased. Tne differential exnainetion showed an inert*** in the perorate** 
of polynuciear cells end & deereese in tha percentage of lyiephocytee lwMrtl nt ely 
after the ultrasonic irredlation. 1 oUcaLng tl*ic, the reverse ceenred, end 
this condition persieted Tor ten hours after the irradiation (lhh). 

In another study tfcere ultreaunlc vevss were applied for prolonged periods 
e decrease in the perteaUsje of leukocytes vas observed, the aaaber of 
erythrocytes, however, remained unchanged. The deereese in the nusber of 
leukocytes, In the opinion of the author, was due to total defeneration and 
vacoulation as veil es a change in the staining properties of the cytephaam 
and neutrophil granules CU£). 

Living and dead e e daran o a undergo changes after ultrasonic therapy. 
With m intensity of 1-3 watts/eta 2 * there uas * rise in the toeperature of 
the ssnbrenea. Swelling of the raawhrnnaa has also been observed which leeda 
tc increased pensaabllity of the sttafcranee (11*6). 

Ultrasonic application to the tissues is found to produes s h a ng a i which 
lead to subsequent daaage to the tissues. Siieiltaneoualy, signs of regener- 
ation of tissues are also evident. Connective tissue shows * eerked pro- 
liferation ea a reaction to ultrasonic irradiation (Hi J). 

Effect on the callus foroation during the heeling process of healthy 
bones has also been studied. High intensi t ies of ultrasonic waves ware weed 
in this study. High intensities caused daaage and even d t a a rp e ar anee of the 
bevy tissue* the daaage in this ease was attributed to the disturbance of 
circulation caused by irradiation. Therapeutic doses, however, are believed 
to be hsraless in this respect (liiB). 

Effects of ultrasonic energy on nervous tissue have been reported. 
Results provided the basis for the developsaent of neuroeonic surgery. 



33 

Different intensities and durations of the application of ultrasonic 
naves have different effeete on the spinal cord. Irradiation at the rate of 
35 watts/cm 2 for u.3 seconds caused paralysis of the dependent parte* This 
paralysis was complete end permanent. Exposure for a shorter period of time 
either caused no paralysis or a >ee|iniai. partial paralysis which disappeared 
after sen* tine. Histological changes were produced after the ir r adi at i on . 
Marked aHymwUM" • were observed in the large motor neurons of the ventral 
horn of the grey Matter. There was a ceaplete destruction of all nerve cells 
and many glia cells. Serious loss of the supporting eleoents occured. The 
lost its namal texture end beeens very soft (lit?). The cell outlines 
ragged and the stain was intense ss corapared to the staining qualities 
of the noreal neurons. Irradiation leading to tesporsry paralysis pro- 
duced slight changes. Low intensities or short durations produced no histo- 
logic^ changes* 

When ultrasonic waves war* applied to the brain or spinal card, a rise 
in the temperature of these structures was observed. The rice in temperatnre 
was not respoajible for the production of changes and effects on the nervous 
system (150). 

» was f owd by Bejel that adverse effects wars produced in the liver 
by ultrasonic energy (151) • Intensities of U watts/en 2 for 1*0 sdnutes ware 
found to affect the liver. Ae early as five Minutes alter irradiation, the 
liver cells lost their capacity to store glycogen. The cells were cofflpletely 
destroyed after f orfc- Minutes ef irradiation. Ksppfer cells also showed 
destruction. Active hyperemia has been observed in the liver after an ultra- 
eonic irradiation of five minutes with ten watts/cm 2 (152). 

Kidaaye. When exposed to ultrasonic waves, showed varying eff ecte 
following different doses of the waves. Use of the dosage of £-6 wattc/e** 



3fc 



restated In oaqplete destruction of sons kidney cells. The changes were 
prmfcieaJ throughout the ©all* The nucleus, however, wes found to be acre 
sensitive tfcsn the cytoplasm (353). 

2h the ovaries, iacressf I atresia of the follicles were observed after 
ultrascnie application of >4* watts/ere 2 . Qra§sneela and the eeacual cycle 
were unaffected. Higher intensities resulted In atrophy of the genital 
tract and sbsolute sterlity (!&)• Effects cf snail doses caused an 
increase of follicular crovth and an early estrous cycle* 

Teetisles, when irradiated with high intensities of ultrasonic waves, 
showed damage at various sites* The sells were effected in the order of 
their decree of saturation* Speraatosoa during the process of division 
were not ynary sensitive to the trauma froa ultrasonic waves {!$$)• 

Effects of ultrasonic waves on the heart vary according to the changes 
in the intensities of the waves* Hearts of cold blooded animals were shown 
to have a decrease in the amplitude of the heart beat after ultrasonic 
irradiiion. In cold blooded animls it was impossible to produce the saas 
changes by aeons of the alterations in the teaperatures* When waves of 
low intensities were spplied to ndce or rabbits, they bees** were active. 
With higwr intensities, however, they beeans paralysed or died (l#). 

Irradiation of the heart with low intensities of ultrasonic waves 
caused a change in the electrocardiograra* The nicest sensitivity to 
ultrasonic waves was rasoifeetsd by the bundle of His* Hun the bundle of 
His was irradiated, cardiac arrest oceured (157). Doses of ultrasonic 
waves which ere used in diagnostic ultrseonograpby, however, produce no 
observable effect on the heart* 



35 



Sauroeonic surgery ref ere to operative procedure on the brain and spinal 
cord performed by the application of focused ultrasonic MRW with inten- 
sities sufficient to cause destruction of nerve cells* 

Brain surgery has been perfects*! either by directly cutting the tissues 
in the brain er by causing sosgulatien of the tissues by means of electrically 
excited probes (!#>)• Both of these Jsetaoda. tsajilwi of extreme care on ths 
part of surgeons, involve ths danger of death or paralysis due to damage to 
surreunding tissues* 

Ton years ago the effects of ultresonlc waves ware being studied at the 
Bioacoustic laboratory at the University of Illinois* frogs ware used in 
this study. High Intensity sewed waves ware applied on the region of back 
over tbe portion of the spinal cord iftieh controls the muscles of the hind 
leg. the sound wavca ware transmitted through water* It use found that 
after a brief exposure the legs became permanently paralysed* It was also 
observed that paralysis did not occur belou a certain level of the intensity 
of ultrasonic waves even when the waves wars applied for a relatively long 
period (163), (UtP), (IS'). 

later the experlmente wire performed on brain of eats and monkeys. 
Fosused waves ware applied on selected regions of the brain end it was 
noted that areas of a few rdlliraeters in length could be affected without 
destroying the neighboring tissues (160)* By this method, a new field in 

neurosurgery was opened* 

Different types of nervous tissues have aide differences in their 
susceptibiliUec to ultrasonic waves* Therefore it is pooaible to destroy 
one type of nervous tissue by adjusting the intensity of the wxvee without 



EXPIAJOnoN QP PLATE III 

A* Four bean focusing ultrasonic irradiator used in 
neuroeonie aurgery. 



B, A »lifiht« lesion in tha eubcortieel unite wetter of 
tha brain of a eat produced in raaponao to a suitably 
choaaa doao of ultrasonic waves. 



c. A 'aediiaa' laeion in tha aubeortieal uhlte nwtter of 
tha brain of a eat produced in reepenee to a auitably 
chosen dose of ultrasonic wares. 



D. A 'heavy 1 lesion in the aubeortieal tfcito sactter of 
the brain of a eat produced in reepenee to a suitably 
chosen dose of ultrasonic wavee. 






Courtcey» Institute of General Senentica 

LakwiHe, Ckmnecticrt, I : . .~. A. 

Lancet Publications, Incorporation 



37 



PLATE III 



A 






>^; 








\M HK * I JB 




klRK f J r# 




X^tfv 




>^wr 



? B 

«« 




\ 




v#) ft* , 






?7l/2mm*J ( 







destroying surrounding tissues, XhiB fact is a great advantage to toe 
neurosonic surgery. In cutting or coagulation aetbcds MM tisanes in tb* 
intervening area have to be destrcyed to reach tho deeired location fear 
surgery. Ho differentiation can be made between news calls, nerve f ibera 
end blood vessels. Moreover* it ie difficult to produce a lesion of a 
definite shape and else by the previous two methods. «hen uitraacaic 
wavee ware used, blood vessels in the area remained unaffected and nerve 
tracts net* act damaged. Unite matter of the brain has been Sound to" be 
mere sueeepteble to ultrasonic destruction than the grey matter. It is 
therefore possible to destroy the nerve fiber tracts surrounded by regions 
of the nerve cell bodies without damaging the tissues of the grey matter (161). 

In the beginning a scows source with a single bsea of waves were used, 
in this way* the lesion produced were swell in cross section but relatively 
long, A lesion that wee email in all three dimensions wee difficult *i 
acconplish with a single beam. A new »ultibee» instrument was later developed 
(162), Tbia instrument produces four beams of ultrasonic waves which converse 
to a point deep within the brain ( see Plats in ). Bach been in its way la 
insufficient in intensity to produce harmful effects, but when essoined at 
the convergent point, the intensity of the waves becomes sufficient enough to 
destruction of the tissues, m this way a lesion can be produced deep 



in the tissues without destroying the intervening area of the brain. The 
aset intense area of the ultrasonic field can produce lesione aa small as a 
few millimeters, 

gsperimnte in neurosonic surgery have revealed that it is possible to 
produce tc^jorary or reversible changes in the tissue structure. This has 
been demonstrated both in the experimental aniawOs and tanas beings (Hi?;, 



39 



Before the application of ultrasonic waves for neuroeurgery, the skull 
eep is removed end the dure istitar ie exposed* The bone of the skull must be 
removed beeense bone has e M£i a illty to absorb ultraexnic waves, Thie 
results in excessive heating which nay affect the bone itself or the under* 
lying tissues (l&)« The presence of bone also disturbs the shape of the 
been of ultrasonic waves. The skin of the patient is attached to a special 
metallic hopper tfiich forms a sort of pan, the bottom of which is formed by 
the exposed dare meter. This pan is filled with degased physiological 
saline solution which serves ee the transmission mediae, 

BswoBonic surgery has opened a new era in the surgery of the brain. 
It nee rendered it relatively safe and easy, Maty of the disorders of the 
nervous system which wore difficult to treat previously, have now become 
possible to be treated succeaafuiay. In addition to the treatment of 
•attain diseases such as Parkinson's disease, hyperkinesias, paresthesias, 
dysesthesias and irradiation of brain tumours, neurosonic surgery has 
f pu mH! a may for additional research in neuroanatomy, na m f u t^h y s lfflogr and 
neuropathology, 

UL3RA9K9HC WLC&C8GCV& 

Increasing research with ultrasonic waves has led to the ittfiifraamsit 
of en ultrasonic i^croecopt, Ultresonic waves with very high frequenciee, 
which also have very short wavelengths, earn be reflected and turned aside 
ia a way similar to light rays. These waves ere used in the ulwaecnic micro* 
scope. The ultresonic beam passes through the object and after being re* 
fleeted by lenses, fonas en enlarged image on e quarts plate. Than image ie 
in the form I nations in the plate and produces electrical sisals. 






These electrical si-rala are ftarthur raade to produce images on an 
oscilloscope in the fo» of a greatly enlarged picture of the object (16£). 

UXBUSCKIC BLOOD FLCHHETH& 

Rcceotty another ultrasonic instrument haa been developed ifcich can 
measure the veloci ty of circulating blood. This inetruaent is baaed upon 
the principle that the difference in frequency between the incident sound 
and the sound reflected frora a raoring target ia proportional to the velocity 
of the target. An ultraaonia blood flowmeter measures the shift in 
frequency of the ultrasonic waves which is applied to the circulating bleed 
and reflects the Telocity of blood (166). 






lltraaonic waves are now being utilised in Medicine; both for 
diagnostic and tl^rapeutlc purposes* 

Piesoelactric effect hat been utilised for the production of ultra- 
aonic waves. These wsvea travel alttoat la straight linos and, In tfcft 
presence of an interface, ere reflected as an echo. In the diagnostic 
ultrasonography, these echoes are recorded and projected on the floureseen* 
screen as rbts of light. Lines of these bright dots are photogrspliod Into 
a ?lct«re, the ultrasonogram. An ultrasonogram can giro a cross-sectional 
picture of the part of body examined. MLagnoatis vatraoonogrspby is being 
utilised in neurology, cardiology, obatetries and gynecology, internal 
medicine, ophthalmology and may <**** branches of mdicine. 

TTltrasoalc waves are also used in medical therapeutics* Ultrasonic 
therapy it associated with an Increase in tlia taspsratare of the tissnas, 
increase in the membrane permeability and tissue absorption, deep massage 
and soothing effect on pain. ttiese Influences of ultrasonic waves asoonnt 
for their utility in therapy. Various di s e ase s of bones. Skin, respiratory 
tract and soma painful conditions can be created with ultrasonic waves* 

ntrasonio vmm are also employed for neurosurgery* Selected parts of 
predetermined else, shape and location in the brain esn be destroyed without 
any hemorrhage or destruction of the murraasttng tissues. Heeroaonls 
surgery is useful .In the treetasnt of certain 



la 



The writer of this report wishes to express his dee© gratitude to 
his aatfor professor, Dr. H. R* Chrlsteneen, Dor his valuable suggestions 
and constant guidance in the preparation of this report* He is also 
indebted to Dr. J. E« Hosier, head of the Depsrtnent of Surgery and 
Medicine, for his kind advisement. 



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h9 



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$0 



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51 



127* Froner, R. and J. Holler, Uber die eimdrkuag too bauchbeeehallungan 
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52 



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Ub6, Craul, . ., Effect of ultrasonic naves on cell n n e s wraiTB , Arch, fur, 
Derrs. und Syphilis 190*6 p, fcG9-l»ll (1950). 

11*7. aieggangtaaser, tf., &a?eriJ»»nteUHBfirpheloBia«he unterauchungen uber 
die wlrkung der ultraschallwellen auf die HaJut, Muskulatvr, 
Here und Incgen das Xaninehens, Baitr, Pathol* Anat, lHiU57 
(1952), 

HjC. Haints, ft*. TiereGperiiaentellc untersuciaingen uber die wirkung der 
lataroachallMBllcn auf die krwehenregeneration, strahlenther 
82*631 (1950), 

lU9# v/ulff. V. J„ at jl» Effects of ultrasonic vibrations on nerve tissues, 
Proc, See, EojiT &ol. Med, 76*361-366 (1951). 



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und auf die kupfferaehen Ptemaellen, Acta, anatonica llikUh 
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on op ranusaac mm zi hbmcdb 



bkmim ram zaihi 

r So«A«H #f Punjab University 
Lahore, Pakietaa, 19S* 



AX ABOTaACT (F A MASTER'S HBKBff 

in partial JtolfiXlaait of tha 



■MRS W MSMM 



Departaant of Sugary and Sarilalaa 



IA8SAS i 



u* 



Ultrasonic waves are now being enployed in medicine both for diagnostic 
and therapeutic purposes. These wavee sere firat utilised daring the First 
World War, when ultrasonic inatroaawta sere developed by the French Asa? *• 
detect enemy submarines. In nediaina aest of the reeeeroh haa been done in 
the peat ten years. 

Piezoelectric effect ie utilised far the production of ultrasonic saves* 
These saves travel almost in straight lines and, In the pr a een ai of an inter* 
face, return as an echo or reflected sound save. The properly of ultrasonic 
saves to be reflected aa m echo from an interface of an object has bean 
utilised for the detection of flaws in metals, the location of subnerlnea 
in the ass and organs in the human body. 

In diagnostic medicine, the echoes frca the interfaces are recorded and 
projected on the oscilloscope or the flourescent screen of the instalment. 
The echoes, by the use of electronic devices, are made to appear on the 
screen as light dote of varying intensity and distance. The distance betsaen 
these dots repreeente the tone which elapses betsaen the pulse being eent out 
and the echo returning to the probe. This gives a measure of the distance of 
the interfaces from the probe. The intensity of the dot represente the 
strength of the returning echo and givee the deneity of the interface. Whan 
lines of those dots are photographed, the picture obtained is the ultraaono- 
grem. An ultrasonogram can give a cross sectional representation of a part 
of the body examined. The soft tissue structures, which ere difficult to 
discriminate in a radiograph, are more easily identified in an ultrasonogram 
An ultrasonogram, aoroover, is obtained without the avperiapoaition of 
structures, which is a characteristic of a radiograph. 

Diagnostic ultrasonography is being utilised in neurology, for the 
detection of brain tuaoure, heraatoaes, intracranial Injuries, and for the 



m of noraal brain atructiircs such ss pituitary and pineal body. 
In cardiology, these waves art used for the diagnosis of aortic and niteral 
stenosis, acvaoaatc of the atrial and ventricular reives end pathological 
structures, euch as tuaware and throabi, present in the heart. In obstetrics, 
these waves *re very useful in the detection of the fetus nuch before it sen 
be detected by radiojjaphic awthods. Determination of the slae and position 
of fetal head is also possible with ultrasonic meres. In ophthalwolocy, 
thee* waves are employed for the neeatireaent of distances between various 
structures; of eye such as lane and retina and in the detection of intra* 
ocular foreign bodies. Oallotones, foreign bodies end tuaours in various 
parte of body can also bs diagnosed with the help of ultrasonic waves* 

Ultrasonic eaves are alao being used far the t reatn e nt of certain diseases* 
ultrasonic therapy is associated with an increase in ths tess>erature of the 
tiosuca, increase la the pcraoahillty of the B*afcranes, agitation or date 
amaage and a soothing effect on pain. These influences of ultrasonic waves 
on the tissues account for their utility in sndical therapy* 

Various diseases of spins and joints such as spondylitis* degeneration 
of intervertebral disc, arthrosis and rheursatie arthritis can be treated with 
ultrasonic waves* Certain cutaneoas conditione such as sclarcdernc, ulcers, 
warta, and inflssnalory processes respond favorably to nltrasenie treataamt* 

High intensities of ultrasonic waves can destroy the nerve cells. Effect 
on these waves in this respect is selective. Ctae type of cells, at a particu- 
lar intensity of waves, aay be destroyed while other types of cells awy resain 
unaffected* This rfrn*T»»» has been utilized in the destruction of selected 
parts of the brain, such as tuaours* This is also used in the production of 
lesions of predeteradned size, shape and location in the brain. She blood 
vessels in the area of the leeion produced in this way *«awdn intact. Brain 



nurgary with the help of ultrasonic naves If reforoed to as » Heorosonic 
surgery ». the ereatest advantage of thin type of swresry is thnt it in- 
volves the least possibility of daaa@ss to the neigiiboring tissues, vbich 
insy lead to hemorrhage, paralyse* or death* 

In recent yean ultrasonic wwree have craHim e d to be an interesting 
subject for research* Work is being done to utilise then in various 
of hiaan and veterinary medicine for better aehievsneata in these fields*